Comprehensive Follow up for Psychiatry 2

Seen by DEPT. OF PSYCHIATRY, Dr. [text]
INFORMANT: [text]
REFERRED BY: [text default="none"]
DIAGNOSED CASE OF: [text default="none"]

CHIEF COMPLAINT: [text]

INTER-CURRENT HISTORY: [textarea]

Psychiatric review of systems is negative for depression, anxiety, psychosis, mania, repetitive behaviors, cognitive symptoms, substance use, personality changes[/textarea]

[remark]Past history start[/remark][checkbox name="ph" value="PAST HISTORY:"][conditional field="ph" condition="(ph).is('PAST HISTORY:')"][textarea][/textarea][/conditional]

[remark]ROS section start[/remark][checkbox name="ros" value="REVIEW OF SYSTEMS:"][conditional field="ros" condition="(ros).is('REVIEW OF SYSTEMS:')"][textarea]As above in Intercurrent history.
Other pertinent constitutional symptoms, HEENT symptoms, cardiac symptoms, respiratory symptoms, gastrointestinal symptoms reviewed and negative[/textarea][/conditional]

[remark]Allerg and med section start[/remark][checkbox name="allmed" value="ALLERGIES AND MEDICATIONS:"][conditional field="allmed" condition="(allmed).is('ALLERGIES AND MEDICATIONS:')"]
[textarea][/textarea][/conditional]

[remark]PE section start[/remark][checkbox name="pe" value="EXAMINATION FINDINGS:"][conditional field="pe" condition="(pe).is('EXAMINATION FINDINGS:')"]
[textarea name="a1" default=".\nHeight cm Weight Kg BMI \nno Pallor | no Cyanosis | no Clubbing | no Lymphadenopathy |\nno Edema | no Malnutrition | no Dehydration\nTemperature Normal | Pulse rate /min, regular\nRespiratory rate /min\nBlood pressure Right Upper Limb mmHg | Left Upper Limb mmHg\nLMP if female pt\n\nSystemic examination findings:\nRS: AEBE, no rales, no ronchi\nCVS: s1,s2 present, no murmur\nAS: pa soft, no guarding/rigidity, no organomegaly\nCNS: no focal abnormalities" cols="70" rows="15"] [/conditional]

MSE:
Appearance: [select value="alert and oriented to time, place and person|OBTUNDED|DISORIENTED|HYPERALERT|-"], [select value="well kempt|POORLY KEMPT|appropriately dressed|INAPPROPRIATELY DRESSED|appropriately groomed|INAPPROPRIATELY GROOMED|DISHEVELED|-"], [select value="normal posture|SLUMPED|RIGID|TENSE|-"]. [textarea cols="20" rows="1"][/textarea]
Behavior: [select value="calm|RESTLESS|AGITATED|RETARDED|PECULIAR|IMPULSIVE|-"], [select value="interactive|WITHDRAWN|-"], [select value="eye contact good|eye contact AVOIDANT|eye contact INTENSE|eye contact FLEETING|-"], [select value="No EPSE|EPSE PRESENT|-"], [select value="No abnormal involuntary movements|ABNORMAL INVOLUNTARY MOVEMENTS PRESENT|-"]. [textarea cols="20" rows="1"][/textarea]
Attitude: [select value="cooperative|HOSTILE|OVER FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE|-"]. [textarea cols="20" rows="1"][/textarea]
Speech: [select name="spontn" value="spontaneous|NON-SPONTANEOUS|MUTISM|-"], [select name="rt" value="N reaction time|INCR REACTION TIME|DECR REACTION TIME|VARIABLE|-"], [select name="rate" value="normal rate|SLOW|POVERTY|PAUCITY|RAPID|OVERTALKATIVE|PRESSURE|-"], [select name="vol" value="normal volume|LOUD|SOFT|WHISPHER|MONOTONE|-"], [select name="rhythm" value="clear rhythm|SLURRED|HESITANT|APHASIC|-"].[textarea cols="20" rows="1"][/textarea]
Mood reported as: [textarea cols="20" rows="1"][/textarea], inferred as-[select value="euthymic|NOT REPORTED|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"]
Affect: quality: [select value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"], [select value="range normal|BROAD|RESTRICTED|-"], [select value="intensity normal|EXPANSIVE|BLUNTED|FLAT|LABILE|-"], [select value="congruent|INCONGRUENT|-"]. [textarea cols="20" rows="1"][/textarea]
Thought form: [select value="coherent|INCOHERENT|CANNOT BE ASSESSED|NOT ENOUGH SAMPLE|-"], [select value="logical and goal directed|-|CIRCUMSTANTIAL|TANGENTIAL|LOOSENING|FLIGHTS OF IDEAS"]. [select value="-|NEOLOGISM|BLOCKING|VERBAL PERSEVERATION"]. [textarea cols="20" rows="1"][/textarea]
Thought content: [select value="no delusion on current evaluation|DELUSION PRESENT|CANNOT BE ASSESSED|-"], [select value="no active suicidal ideations at present| SUICIDAL IDEATIONS PRESENT|DEATH WISHES PRESENT|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea]
Perception: [select value="no hallucination on current evaluation|HALLUCINATION|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea]
Insight: [select value="present|PARTIAL|POOR|MOSTLY BLAMES OTHERS|DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea]
Judgment: [select value="intact|IMPAIRED|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"][/textarea]
Cognition: [select value="Clinically intact|ABNORMALITIES PRESENT|PENDING|CANNOT BE ASSESSED|-"]. [textarea default="normal attention, concentration, intact ability to recall recent and remote information, normal abstraction" cols="50" rows="3"][/textarea]

ASSESSMENT/PLAN:
[textarea]pt counseled
refer 
omit 
add 
increase 
continue 
x 
follow up after [/textarea]